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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 11  |  Issue : 1  |  Page : 7-13

Diode lasers for pediatric endodontics: State-of-the-art!


MMNGH Institute of Dental Sciences and Research Centre, Rajiv Gandhi University of Health Sciences, Belagavi, Karnataka, India

Date of Web Publication23-Jun-2017

Correspondence Address:
Rashmi G Naik
MMNGH Institute of Dental Sciences and Research Centre, Rajiv Gandhi University of Health Sciences, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdl.jdl_1_17

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  Abstract 

Introduction: Conventional chemomechanical debridement (CMD) of deciduous root canals can significantly reduce the intracanal bacterial load but cannot assure predictable disinfection due to the inherent anatomical complexities. Newer methods are thus being employed to enhance the efficacy of pediatric endodontic disinfection, and the use of laser technology is at the forefront of this endeavor. Aim: The aim is to assess the efficacy of diode laser-assisted disinfection in comparison to conventional sodium hypochlorite (NaOCl) based CMD in deciduous root canals. Materials and Methods: A total of 12 patients aged 5–8 years of both genders were selected. Local anesthesia was administered and rubber dam isolation achieved. Access opening was done and the roof of the pulp chamber was removed. A sterile paper point compatible with the anatomic diameter of the canal was introduced and left in place for 30 s ( first sample) which was then transferred into an Eppendorf tube containing reduced transport fluid medium. CMD was performed up to 25 number K-file with intermittent 3% NaOCl irrigation. Post-CMD, sterile number 25 paper points were introduced as above (second sample). Thereafter, an 810 nm diode laser (1W, CW) with a specific endodontic E-200 tip was introduced into the root canals 2 mm short of the radiographic apex and was gently withdrawn in a helical zigzag motion. Another sample was then taken using a sterile No. 25 paper point (third sample) and transported to the microbiological laboratory for culture. Results: The mean reduction in colony forming units postdiode laser application was seen to be 100% when compared to 98.46% reduction after CMD with 3% NaOCl.
Conclusion: An 810 nm diode laser can be used as an effective adjunct to conventional methods of deciduous root canal disinfection.

Keywords: Diode laser, root canal disinfection, sodium hypochlorite


How to cite this article:
Naik RG, Raviraj G A, Yavagal CM, Mandroli P. Diode lasers for pediatric endodontics: State-of-the-art!. J Dent Lasers 2017;11:7-13

How to cite this URL:
Naik RG, Raviraj G A, Yavagal CM, Mandroli P. Diode lasers for pediatric endodontics: State-of-the-art!. J Dent Lasers [serial online] 2017 [cited 2017 Aug 17];11:7-13. Available from: http://www.jdentlasers.org/text.asp?2017/11/1/7/208940


  Introduction Top


The main goal of endodontic therapy in primary teeth is to maintain an intact dental arch, a healthy periodontium, and the vitality of the dental pulp whenever possible.[1] The key determinants of the success of such an intervention depend on a host of factors such as accurate diagnosis, thorough canal cleaning, and more importantly an irrigation protocol that is predictable. Along with prudent irrigation methods, an optimum usage of intracanal medicaments should also be considered before the ultimate placement of a final restoration.[2]

Although chemomechanical debridement (CMD) is an indispensable part of root canal therapy, several investigations have showcased its shortcomings due to restrictions posed by a deeper penetration of the bacteria into anatomical complexities, namely, accessory canals, apical branches, isthmuses, and dentinal tubules, particularly in the apical one-third of a deciduous root canal.[3]

An ideal irrigation solution should be strongly antimicrobial but not toxic to the periradicular tissues when extruded through the apical foramen.[4] Sodium hypochlorite (NaOCl) happens to be the most commonly used irrigating solution. It acts as a potent antimicrobial agent and also has the ability to dissolve organic components of dentin such as the pulpal remnants and collagen. In addition, it is inexpensive, has a long shelf life, and is readily available. Although it is the most commonly used irrigant, it has an unpleasant odor and taste, and its extrusion into periapical tissues can cause excruciating pain, immediate swelling, and profuse bleeding. When used in pediatrics, it can also damage permanent tooth follicles, peripheral tissues, and oral mucosa when used at full strength.[2] So to reduce these side effects, there is a need to use the same irrigant at a lesser concentration in children but not with a compromise in its disinfecting ability. Thus, a concurrent use of a safe adjuvant with it is the need of the hour.

In this regard, laser-assisted endodontic disinfection has gained significant acceptance. Although different wavelengths could be used for this purpose, the near-infrared range from 810 to 980 nm is considered most suitable due to its greater depth of penetration.[3]

The use of laser technology is noninvasive, nonresistant, and extremely predictable.[5] Of the available options, the diode seems to be the most practical choice and is definitely worth considering for the aforementioned purpose. These portable diodes have already proved their efficacy and versatility in several other clinical applications thus becoming commonplace at many contemporary operatories. So considering these factors, the present investigation was planned to evaluate the efficacy of the 810 nm diode laser as an adjunct for endodontic disinfection of deciduous root canals.


  Material and Methods Top


The study was conducted on 12 children of both genders in the age group of 5–8 years, recruited from the outpatient clinics of the Department of Pediatric Dentistry, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belagavi, Karnataka, India.

The study was approved by the Institutional Review Board and Ethical Committee. Informed consent was obtained from the parents and assent was obtained from the children before the start of the study.

The inclusion criteria for the cases were in accordance to Pinheiro et al.[6] which are mentioned below:

  1. Advanced carious lesions of deciduous teeth affecting the pulp evidenced by an intraoral periapical radiograph
  2. Deciduous teeth with at least 2/3 of root length
  3. Absence of internal or external pathological root resorption
  4. Absence of internal and/or external perforation in the furcal area
  5. Children not having undergone any medical treatment/not having received antibiotics within 90 days preceding the study.


The exclusion criteria were as follows:

  1. Necrotic pulps in teeth with a radiolucent area in the furcation recommended for exodontics
  2. Deciduous teeth with radicular resorption of more than half of the total root length
  3. Obliterated root canals.


Clinical procedure

Local anesthesia was administered [Figure 1] with lignocaine (Lidayn, Health Biotech Ltd, Solan, India) and rubber dam (Hygenic, Coltene/Whaledent) was placed for isolation. Access opening was achieved, and the roof of the pulp chamber was removed with a spherical rotary round bur no. 2 [Figure 2]. The root length was measured with the help of digital radiovisiography (X-ray vision, SATELAC). A sterile paper point compatible with the anatomic diameter of the root canal was introduced into each canal and left in place for 30 s [Figure 3]. This was the first sample (Group 1) which was immediately transferred into an Eppendorf tube containing reduced transport fluid (RTF) medium.[7] A number 10 K-file (MANI, Inc., Japan) was used to negotiate the root canals and CMD was performed up to 25 number K-file with intermittent 3% NaOCl (Vensons, India) irrigation [Figure 4]. Sterile number 25 paper points (MANI, Inc., Japan) were introduced into the debrided canals [Figure 5] and transferred into an Eppendorf tube containing RTF medium (second sample – Group 2). Thereafter, 810 nm diode laser (Elexxion, Germany) [Figure 6] and [Figure 7] with a specific endodontic E-series tip of 200 μm diameter [Figure 8] operating at 1W/CW was introduced into the root canals [Figure 9] 2 mm short of the radiographic apex.[8] While the laser was irradiated, the tip was gently withdrawn from the root canal in a helical zigzag motion over 15 s, repeated for three cycles with intermittent 3% NaOCl irrigation. A third sample was then taken using a sterile No. 25 paper point (Group 3) [Figure 10]. All the samples transported to microbiological laboratory [Figure 11] for the culture of aerobic and anaerobic microorganisms.
Figure 1: Local anesthesia administration

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Figure 2: Rubber dam placement and access opening

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Figure 3: Collection of first sample

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Figure 4: Irrigation with 3% sodium hypochlorite

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Figure 5: Collection of second sample

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Figure 6: Laser Kit

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Figure 7: “Elexxion” 810nm Diode Laser

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Figure 8: Endodontic E-series tip 200μm

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Figure 9: Introduction of Diode Laser into the root canal

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Figure 10: Collection of third sample

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Figure 11: Eppendorf tubes containing samples

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Microbiological sampling and culture

All the samples were cultivated to detect the total number of viable bacteria. Homogenization was performed for 3 min in a tube agitator [Figure 12]. Sowing was performed using three aliquots seeded with a micropipette onto the surface of blood agar plates (Himedia, India) [Figure 13]. The plates were incubated in anaerobic jars (Oxoid Inc.) for 5 days at 37°C in 85% nitrogen, 10% carbon dioxide, and 5% hydrogen atmosphere [Figure 14]. After 5 days, the total numbers of viable bacteria unit-forming colonies (ufc) were determined for each sample [Figure 15] and [Figure 16] using colony counter by a blinded assessor.[6]
Figure 12: Vortexing of sample

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Figure 13: Seeding on blood agar plate

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Figure 14: Incubation in anaerobic jar

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Figure 15: Colonies on mannitol salt agar plates before, postchemomechanical debridement and postlaser, respectively

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Figure 16: Culture done on mannitol salt agar, blood agar, Rogosa agar plates

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Statistical analysis

IBM Statistical Package for the Social Sciences statistics version 17.0 was used and the data were analyzed using the Friedman's test followed by the Wilcoxon test with the level of significance set at P< 0.05.


  Results Top


The ufc/ml before CMD, after CMD using 3% NaOCl and postlaser treatment are shown in [Table 1] and [Table 2]. The mean ufc/ml before CMD, post-CMD with 3% NaOCl and postlaser treatment are depicted in [Graph 1],[Graph 2],[Graph 3],[Graph 4]. The mean reduction in the ufc post-CMD with 3% NaOCl was found to be 98.46%, whereas the mean reduction in the ufc postlaser treatment was observed to be 100%. This difference was highly statistically significant (P = 0.028).
Table 1: Total viable microbiological count (ufc/ml) before chemomechanical debridement, postchemomechanical debridement and postlaser

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Table 2: Mean viable microbiological counts (ufc/ml) before chemomechanical debridement, postchemomechanical debridement and postlaser

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  Discussion Top


The elementary goal of any endodontic intervention is to prevent or cure periapical pathology by a maximal reduction in the number of causative pathogens. The success of endodontic therapy thus depends on the ability to obtain a sterile root canal before obturation of the root canal space. This is achieved by appropriate chemo-mechanical debridement of the root canal followed by optimal irrigation protocol.[9]

Different irrigating solutions, namely, NaOCl, chlorhexidine, ethylenediaminetetraacetic acid, MTAD etc., are used which result in a reduction of the total microbial count with a modest drop in Enterococcus faecalis levels.[10] However, no irrigant till date has managed to completely eliminate all the microorganisms from infected root canals.[11]

Long-term treatment failures and resistance to endodontic therapy are often observed when there is a hindrance to the complete depth of irrigant penetration. Moreover, microorganisms in the deeper layers of dentin are not affected due to the insufficient depth of penetration of the irrigant.[12] Of all the technological advances that have been tried to address the above shortcomings of conventional CMD, laser-assisted endodontic disinfection has gained maximal acceptance. It has been established that laser energy can eliminate microorganisms existing in the complex anatomical areas such as accessory canals, apical branches, isthmuses, and lateral canals.[13] The present study thus focused on the evaluation of the efficacy of an 810 nm diode laser when used as an adjunct to conventional CMD in deciduous root canal disinfection. The choice of the wavelength was dictated by the superior disinfection rates reported by similar studies which had used the near infrared range of the electromagnetic spectrum.[14]

In this study, 98.46% of disinfection was achieved by 3% NaOCl. This could be justified by the findings of Berutti who had demonstrated that chemical disinfectants like NaOCl penetrate no more than 130–300 μm of dentin.[15]

Gutknecht et al. used diode laser for disinfection of root canals contaminated by E. faecalis to differing dentin thicknesses of up to 500 μ depth. The results demonstrated that diode laser with 980 nm wavelength can eliminate bacteria which have penetrated to a depth of 500 μ in dentin.[16]

In another study conducted by Kreisler et al., Gallium Aluminum Arsenide (diode 809 nm) laser was used alone and in combination with NaOCl and oxygenated water. Laser parameters set were continuous mode (CW) at 1/5, 3 and 4/5 W power with 20 μ diameter fiber for 60 s and results showed that bacterial reduction was more remarkable in the group combining laser with an irrigating solution.[17] Hence, we used a similar protocol in conjunction with 3% NaOCl.

The resultant 100% bacterial kill achieved in the present study further validate the outcomes of previous interventions by Mehrvarzfar et al. who had suggested that a combination therapy of chemical irrigation and laser irradiation could totally eliminate all root canal pathogens including the dreaded E. faecalis.[18] In a similar study, the previous authors had also concluded that laser irradiation following chemomechanical irrigation was more effective than NaOCl irrigation alone for eliminating E. faecalis.[19]


  Conclusion/limitations/futuristic Perspectives Top


The adjunctive use of lasers have tremendously influenced the outcomes of conventional endodontic interventions. Accessibility to the formerly unreachable parts of the root canal has now become commonplace with lasers. In this study, 100% canal disinfection was achieved by an 810 nm diode laser, but further long-term follow-ups are needed. Furthermore, we need more research and multicentric inputs before we could reach a consensus to standardize the protocol as well as the settings needed to make this art and science of laser-assisted pediatric endodontics, a predictable one!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Goel A, Madan M, Singh P, Kandari S. Recent advances in Pediatric Endodontics. Indian Journal of Dental Sciences 2014;6:87.  Back to cited text no. 1
    
2.
Ramachandra JA, Nihal NK, Nagarathna C, Vora MS. Root canal irrigants in primary teeth. World J Dent 2015;6:229-34.  Back to cited text no. 2
    
3.
Chiniforush N, Pourhajibagher M, Shahabi S, Kosarieh E, Bahador A. Can antimicrobial photodynamic therapy (aPDT) enhance the endodontic treatment? J Lasers Med Sci 2016;7:76-85.  Back to cited text no. 3
    
4.
Kapdan A, Kustarci A, Tunc T, Sumer Z, Arslan S. KTP laser and ozone in primary root canals. Niger J Clin Pract 2015;18:538-43.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kaiwar A, Usha HL, Meena N, Ashwini P, Murthy CS. The efficiency of root canal disinfection using a diode laser: In vitro study. Indian J Dent Res 2013;24:14-8.  Back to cited text no. 5
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6.
Pinheiro SL, Silva JN, Gonçalves RO, Villalpando KT. Manual and rotary instrumentation ability to reduce Enterococcus faecalis associated with photodynamic therapy in deciduous molars. Braz Dent J 2014;25:502-7.  Back to cited text no. 6
    
7.
Prabhakar AR, Yavagal C, Agarwal S, Basappa N. Antimicrobial effects of laser-assisted photodynamic therapy in pediatric endodontic treatment: A new clinical horizon. Int J Laser Dent 2013;3:77-81.  Back to cited text no. 7
    
8.
Olivi G. Laser use in endodontics: Evolution from direct laser irradiation to laser-activated irrigation: A scientific review. J Laser Dent 2013;21:58-71.  Back to cited text no. 8
    
9.
Gunwal M, Shenoy P. Evaluation of the efficacy of 5.25% of sodium hypochlorite, 2% of chlorhexidine, MTAD and 810 diode laser in reduction of microbial count in root canal: An in vivo study. J Endod 2013;25:56-62.  Back to cited text no. 9
    
10.
Ahangari Z, Samiee M, Yolmeh MA, Eslami G. Antimicrobial activity of three root canal irrigants on Enterococcus faecalis: An in vitro study. Iran Endod J 2008;3:33-7.  Back to cited text no. 10
    
11.
Souza LC, Brito PR, de Oliveira JC, Alves FR, Moreira EJ, Sampaio-Filho HR, et al. Photodynamic therapy with two different photosensitizers as a supplement to instrumentation/irrigation procedures in promoting intracanal reduction of Enterococcus faecalis. J Endod 2010;36:292-6.  Back to cited text no. 11
    
12.
Kouchi Y, Ninomiya J, Yasuda H, Fukui K, Moriyama T, Okamoto H. Location of Streptococcus mutans in the dentinal tubules of open infected root canals. J Dent Res 1980;59:2038-46.  Back to cited text no. 12
    
13.
Asnaashari M, Safavi N. Disinfection of contaminated canals by different laser wavelengths, while performing root canal therapy. J Lasers Med Sci 2013;4:8-16.  Back to cited text no. 13
    
14.
Ashofteh K, Sohrabi K, Iranparvar K, Chiniforush N.In vitro comparison of the antibacterial effect of three intracanal irrigants and diode laser on root canals infected with Enterococcus faecalis. Iran J Microbiol 2014;6:26-30.  Back to cited text no. 14
    
15.
Berutti E, Marini R, Angeretti A. Penetration ability of different irrigants into dentinal tubules. J Endod 1997;23:725-7.  Back to cited text no. 15
    
16.
Gutknecht N, Franzen R, Schippers M, Lampert F. Bactericidal effect of a 980-nm diode laser in the root canal wall dentin of bovine teeth. J Clin Laser Med Surg 2004;22:9-13.  Back to cited text no. 16
    
17.
Kreisler M, Kohnen W, Beck M, Al Haj H, Christoffers AB, Götz H, et al. Efficacy of NaOCl/H2O2 irrigation and GaAlAs laser in decontamination of root canals in vitro. Lasers Surg Med 2003;32:189-96.  Back to cited text no. 17
    
18.
Mehrvarzfar P, Saghiri MA, Asatourian A, Fekrazad R, Karamifar K, Eslami G, et al. Additive effect of a diode laser on the antibacterial activity of 2.5% NaOCl, 2% CHX and MTAD against Enterococcus faecalis contaminating root canals: An in vitro study. J Oral Sci 2011;53:355-60.  Back to cited text no. 18
    
19.
Rahimi S, Shahi S, Gholizadeh S, Shakouie S, Rikhtegaran S, Soroush Barhaghi MH, et al. Bactericidal effects of Nd:YAG laser irradiation and sodium hypochlorite solution on Enterococcus faecalis biofilm. Photomed Laser Surg 2012;30:637-41.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
 
 
    Tables

  [Table 1], [Table 2]



 

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